End-Of-Life Care Communication in Long-Term Care Among Nurses, Residents, and Families: A Critical Review of Qualitative Research

Mechanisms of end-of-life communication contributing to optimal care at the end of life: a review of reviews

BACKGROUND

End-of-life communication is an essential component of high-quality care, but its potential mechanisms for improving care are not well understood.

OBJECTIVES

To summarise the potential mechanisms by which end-of-life communication may contribute to enhanced end-of-life care in any setting.

DESIGN

An overview of systematic reviews, with a narrative synthesis of results. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Study quality was assessed using the AMSTAR (A MeaSurement Tool to Assess Reviews) tool.

DATA SOURCES

CINAHL, MEDLINE, Cochrane, SSCI and PsycINFO databases, were searched from inception to January 2024. Manual searches were also conducted.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Systematic reviews (published in English) related to end-of-life communication, where the target population was adult patients in their last year of life, relatives, caregivers and/or healthcare professionals involved in communicating with dying patients.

RESULTS

We reviewed 35 eligible studies. The reviews suggest potential mechanisms of effective end-of-life communication including collaborative decision-making, tailoring communication to individuals, using effective communication strategies and incorporating communication skills into practice. The reviews also highlighted barriers related to patients, professionals and organisations.

CONCLUSION

This review highlights a nuanced understanding of potential mechanisms of end-of-life communication, emphasising the need for tailored training, policy enhancements and interprofessional collaboration. It calls on healthcare professionals to reflect on their practices, advocating for co-designing a person-centred communication model that addresses patient preferences at the end of life. Importantly, in culturally diverse contexts, there is a need for a communication paradigm that embraces diversity to provide truly empathetic and effective end-of-life care. This concise roadmap may foster compassionate, dignified and effective end-of-life communication.

TRIAL REGISTRATION NUMBER

Protocol registered with PROSPERO (CRD42022271433, 29 March 2022).

A Parallel Process of Staff-Family Distress in Long-Term Care: A Challenge to Collaboration

Introduction

Supporting persons living with advanced dementia in long-term care (LTC) homes requires strong collaborative partnerships between staff, family members, and residents. Yet, relational tensions-such as differing expectations around care decisions-can inhibit the implementation of collaborative partnerships at this critical point in the trajectory of care.

Objective

This study aims to explore the emotional experiences of families and staff during shared decision-making processes for individuals with advanced dementia in LTC.

Method

Guided by interpretative description, this qualitative study investigated the experiences of staff (n = 12) and families (n = 16) collaborating in two Canadian LTC homes. Data was collected through semistructured interviews lasting 45-60 min, which facilitated a detailed exploration of participants' narratives. The interviews were audio-recorded, transcribed, and analyzed using reflexive thematic analysis facilitated by a combination of inductive and deductive approaches.

Results

Our analysis revealed a complex parallel process of trauma and grief including accumulated distress, isolation, and feelings of devalue that worked together to create distance between staff and families at a time when connection was critical. Our findings further suggested that a lack of time and space for reflection and validation for staff and family, resulted in a cycle whereby staff and families engaged in a push and pull dynamic with each viewing the other as adversaries rather than allies.

Conclusion

Our findings highlight the critical need for reflexive opportunities in LTC homes to overcome and attend to the emotional barriers that interfere with true collaboration between staff and families. We hope that the proposed cycle serves as a preliminary framework to support staff in navigating difficult conversations and emotions, and fosters reflexive care that enhances, rather than obstructs, connections.

Preferences and Attitudes Towards Life-Sustaining Treatments of Older Chinese Patients and Their Family Caregivers

Purpose

The family plays a major role in medical decision-making in China. Little is known about whether family caregivers understand patients' preference for receiving life-sustaining treatments and are able to make decisions consistent with them when patients are incapable of making medical decisions. We aimed to compare preferences and attitudes concerning life-sustaining treatments of community-dwelling patients with chronic conditions and their family caregivers.

Patients and Methods

We conducted a cross-sectional study among 150 dyads of community-dwelling patients with chronic conditions and their family caregivers from four communities in Zhengzhou. We measured preferences for life-sustaining treatments (cardiopulmonary resuscitation, mechanical ventilation, tube feeding, hemodialysis, chemotherapy), who should decide, the timing of making decisions, and their most important consideration.

Results

The consistency of preferences for life-sustaining treatments between patients and family caregivers was poor to fair, with kappa values ranging from 0.071 for mechanical ventilation to 0.241 for chemotherapy. Family caregivers more frequently preferred each life-sustaining treatment for the patients than the patients themselves. More family caregivers than patients preferred the patient to make their own decisions about life-sustaining treatments (29% of patients and 44% of family caregivers). The most important considerations when deciding on life-sustaining treatments are family burden and the patient's comfort and state of consciousness.

Conclusion

There is a poor to fair consistency between community-dwelling older patients and their family caregivers in their preferences and attitudes towards life-sustaining treatments. A minority of patients and family caregivers preferred that patients make their own medical decisions. We recommend healthcare professionals to encourage discussions between patients and their families on future care to improve the mutual understanding within the family about medical decision-making.